Provider Demographics
NPI:1760787154
Name:PETERSON, CAROLINE CROUCH (ATR-BC, LPC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CROUCH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CARPENTER LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3401
Mailing Address - Country:US
Mailing Address - Phone:215-528-2138
Mailing Address - Fax:
Practice Address - Street 1:530 CARPENTER LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3401
Practice Address - Country:US
Practice Address - Phone:215-528-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004590101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional